Primary Survey

Question 1

When to put out a trauma call.

a) Mechanism
b) Patient factors
c) Specific injuries
d) Patient observations

Answer 1

a) - Fall from height > 3 feet (5 steps)
- High velocity - RTC, bicycle crash
- Axial load to head - eg. diving
- Penetrative - eg. stabbing, gun shot, explosion
- Burns, flames, smoke inhalation

b) - Pregnancy
- Elderly/ at risk

c) - Pneumothorax
- Flail chest
- Reduced GCS/
- Massive haemorrhage
- Head injury

d) - Shock
- Unstable/ deteriorating

Question 2

ATMIST

Answer 2

Age
Time of arrival/ time of event
Mechanism of injury
Injuries suspected
Signs (vitals)
Treatments already initiated (by paramedics, pre-hospital team)

Question 3

Red phone goes off - high speed RTC. Patient blue-lighted and will arrive in 5 minutes
- what should you prepare

Answer 3

• Put out trauma call
• Assesmble team and brief team
• Allocate roles - team leader
• Prepare kit
• Contact CT
• Pre-alert blood bank

Question 4

ED trauma team

Answer 4

• Team leader (usually most senior member of ED team)
• Airway (anaesthetist ideally)
• Primary survey clinician
• Circulatory access and bloods
• 2x nursing staff - airway assistance, observations and drug administration
• Radiographer
• Scribe

Question 5

Hospital trauma team (tertiary trauma centre)*

*DGH will just have ED trauma team

Answer 5

• General surgery
• Orthopaedics
• Anaesthetics/ITU
• Cardiothoracics
• Vascular
• Obstetrics
• Paeds
• Radiology

Question 6

cABCDE

Answer 6

Catastrophic haemorrhage
Airway
Breathing
Circulation
Disability
Exposure

Question 7

Catastrophic haemorrhage

a) What is it? - causes?
b) Management

Answer 7

• Immediate* life threatening exsanguination (eg. amputation or other profuse bleeding point)
• Apply torniquet or compression bandage
  +/- haemostat agents (eg. Quikclot)

*Will kill you before an airway problem

Question 8

Airway.

a) and ….?
b) What is triple immobilisation
c) How to assess airway?
d) Signs of obstruction
e) Causes of traumatic airway problem
f) Management

Answer 8

a) C-spine stabilisation

b) Collar, blocks and tape
(also will be on a spinal board)

c) - Are they speaking with normal voice?
- Look in and around the mouth (eg. blood, vomit, loose teeth, max-fax injuries)
- Listen to breathing
- Look at chest movements

d) - Listen (stridor, snoring, grunting, secretions)
- See-saw breathing
- Cyanosis, hypoxia
- Hoarse voice (?inhalation injury - look for ), drooling

e) - Reduced GCS
- Burns - inhalation injury (look for facial burns, singed eyebrows/eyelashes, carbaceous sputum)
- Facial injury

f) - Suction
- Airway manoeuvres
- Adjuncts
- Intubate (alert anaesthetics)
- Front of neck access - cricothyroidotomy and create tracheostomy

Question 9

Breathing

a) assessment
b) imaging?
c) management

Answer 9

a) - Observations - SpO2, RR
- Look - any obvious injuries, fractures, wounds, flail chest, respiratory distress, etc.
- Palpate - expansion, tenderness
- Percuss (?pneumothorax, haemothorax)
- Auscultate - air entry, added sounds

b) - Not for tension pneumothorax - clinical diagnosis!
- Haemothorax - whiteout of hemithorax

c) - Tension/large pneumothorax - needle decompression, chest drain, open pneumothorax - needs dressing
- Haemothorax - if massive, IV access, bloods + fluids (consider major haemorrhage protocol), then chest drain
- Flail chest - pain relief, may need nerve block
- Oxygen
- Ventilation

Question 10

Circulation.

a) assessment
b) management
c) where can be blood be lost to?
mnemonic: 1 on the floor + 4 more
d) imaging?

Answer 10

a) - Observations - tachycardic, hypotensive
- CRT, pulse volume, temperature (cool peripheries), colour (pale, cyanosed)

b) - IV access
- Bloods
- Fluids
- Blood products
- Consider major haemorrhage protocol
- Pelvic binders and splints
- Needle pericardiocentesis/ open thoracotomy
- ITU if need vasopressors/inotropes
- Surgery - vascular, orthopaedics, cardiothoracic, obstetric, etc.

c) - 1 on the floor (check bed, clothes + surroundings)
- and 4 more: thorax, abdomen, pelvis, long bones
- Consider tamponade in penetrating chest trauma

d) FAST scan
- Focused Assessment with Sonography for Trauma
- US scan
- Looks in hepatorenal angle, splenorenal angle, suprapubic space for free fluid in abdomen
- Also looks at pericardium for tamponade (Beck’s triad: muffled heart sounds, hypotension, raised JVP)

Other

• ECHO
• Angiogram
• CXR

Question 11

Disability.

a) 3 core things always to assess
b) Specifically for trauma
c) Outline GCS

Answer 11

a) GCS/AVPU, pupils, glucose

b) Head injuries.
- ?boggy mass, signs of basilar fracture
- pupillary reflexes, AVPU, GCS
- other neurology - sensory level, weakness, CES / cord compression, etc.
- Log rolling - maintains spinal alignment while moving patient for patients with suspected spinal injury

DEFG - glucose

c) - E4 - spontaneous, to voice, to pain, no opening
- V5 - VOICE (voiceless,
- M6 - OLDBEN (obey commands, localise to pain, draws from pain, bends, extends, no response)

Question 12

Exposure.

Answer 12

• Temperature - beware hypothermia
• Abdomen
• Long bones
• Pressure areas
• Urinary retention - could be blood clot causing this, indicating urological trauma

Question 13

Life threatening diagnoses in the chest to look for in primary survey.
- Mnemonic: ATOM FC

Answer 13

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest
• Cardiac tamponade

Question 14

After primary survey.

a) Initially
b) Then

Answer 14

a) - Stable - CT scan
- Unstable - durther resus / theatres/ ITU

b) Secondary survey.
- Top to toe survey